Bellhaven Center for Rehab and Nursing Care

Inspectors wroteBased on record review and interviews during the survey, the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for three (3) (unit A1, B2, and C2) of six (6) units during the sufficient and competent nurse staffing review task. Specifically, a review of the Payroll-Based Journal Staffing Data Report, the facility assessment, and the daily staffing revealed that on multiple days the facility did not have adequate staffing to meet the residents' needs as indicated in the Facility Assessment.

Inspectors wroteBased on observations, interviews and record review during the survey, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #9) of one (1) resident reviewed for dignity. Specifically, Resident #9 had a Foley catheter and was observed in the dining room without a privacy cover on the Foley catheter drainage bag. The Foley catheter drainage bag was filled with yellow colored urine and was visible to other residents and staff. Licensed Practical Nurse #3 subsequently wheeled the resident to the hallway sitting area with other residents present and did not cover the drainage bag with a privacy cover.

Inspectors wroteBased on interviews and record review during the recertification survey, the facility failed to ensure a resident was from physical or chemical restraints imposed for the purpose of discipline or convenience and are not required to treat the resident's medical symptoms. This was evident for one (1) of five (5) reviewed for unnecessary medications. Specifically Resident #24 with a diagnosis of dementia had a physician's order for quetiapine (Seroquel-a psychotropic/antipsychotic medication) for major depressive disorder. At the resident's family member's request, the quetiapine dosage was increased from 100 milligrams per day to 150 milligrams per day without documented evidence of clinical justification.

Inspectors wroteBased on observations, record review, and interviews during the survey, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. This was identified for one (1) (Resident #119) of one (1) resident reviewed for skin conditions and for one (1) (Resident #15) of three (3) residents reviewed for pressure ulcers. Specifically, 1) Resident#119's physician orders and comprehensive care plan indicated use of a Geri sleeves (protective sleeves designed to safeguard fragile skin) on both arms for senile purpura (age related skin thinning and bruising). On two separate occasions, the resident was observed without the use of the Geri sleeves as ordered. 2) Resident #15 had a physician's order for a bed cradle at the foot of the bed every shift while in bed to prevent the sheets from directly touching the resident's feet. [...]

Inspectors wroteBased on interviews and record review during the survey, the facility failed to review and revise the comprehensive person-centered care plan by the interdisciplinary team after each assessment. This was identified for one (1) (Resident #119) of one (1) resident reviewed for skin conditions. Specifically, Resident #119's comprehensive care plan for behaviors was not updated to include noncompliance behaviors related to removal of wound dressings and Geri repeated pulling of dressing and Geri sleeves (protective sleeves designed to safeguard fragile skin).

Inspectors wroteBased on observations, interviews and record review during survey, the facility failed to ensure that each resident received treatment and care based on their comprehensive assessment and in accordance with professional standards of practice. This was identified for one (1) (Resident #229) of one (1) resident reviewed for activities of daily living. Specifically, on 05/15/2026, Resident #229 was observed with edema (swelling) on both lower extremities and had ace wraps (elastic bandage) applied on both lower legs. The ace wraps were not applied properly as the skin was visible in between the bandaged ace wrap layers. The ace wrap was excessively tight as evidenced by visible bulging/protruding skin between the wrapped layers. Additionally, the resident's physician was not notified of reoccurrence of the bilateral lower extremities' edema.

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for one (1) (Resident #1) of four (4) residents reviewed for accident hazards. Specifically, an unlabeled medication cup containing topical wound dressing paste was observed in Resident #1's room. There were no staff in the vicinity of the room.

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #119) of eight (8) residents reviewed for infection control task. Specifically, Resident #119 had a physician's order for enhanced barrier precautions (transmission-based precautions to prevent the spread of infection) for tube feeding and foley catheter use. On 05/18/2026 Resident #119's foley catheter was dislodged. Registered Nurse #1 entered the resident's room without wearing a gown. [...]

Inspectors wroteBased on record review and an interview with the facility Administrator during the survey, the facility failed to document the resources that were necessary to care for its residents competently during daily operations and emergencies. Specifically, the facility assessment did not include the use of agency Licensed Practical Nurses and use of Safety Aides to provide resident care.

Inspectors wroteBased on observation, record review, and staff interview during the abbreviated survey (NY00375947) the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for four (4) of 27 residents (Resident #1, #2 and #3, #4) reviewed. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. The facility failed to protect all four (4) residents from the likelihood of entrapment. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy and Substandard Quality of Care to all residents' using bedrails health and safety.

Inspectors wroteBased on observations, record review and interviews during the abbreviated Survey (complaint # NY00375947) the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for four (4) (Resident #1, #2, #3 and #4) of twenty-seven (27) residents with the potential to affect all 27 residents. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. [...]

Inspectors wroteBased on observations, record review, and interviews during the abbreviated survey complaint # (NY00375947) the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented appropriate plans of action to correct identified issues with the facility's side rail padding concern identified for four (4) of twenty-seven (27) residents (Resident #1, #2, #3 and #4) reviewed. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. Additionally, the facility had blankets and pillows attached with tape to the siderails of four (4) of four (4) residents siderails in place of side rail pads further adding to the likelihood of entrapment. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey and Abbreviated Survey (NY 00336468) initiated on 8/14/2024 and completed on 8/21/2024, the facility did not ensure that all incidents including an injury of unknown origin were thoroughly investigated. This was identified for one resident (Resident #430) of six residents reviewed for Accidents. Specifically, on 3/19/2024 Resident #430 sustained a fracture of their left leg, an injury of unknown origin. The facility did not thoroughly investigate the incident to identify the root cause of the injury to rule out abuse, neglect, and mistreatment. The finding is: The facility's policy titled Accidents/Incidents Involving Residents revised in July 2021 documented the facility's aim is to protect all the residents from accidents and incidents. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. This was identified for one (Resident #132) of two residents reviewed for hearing and vision. Specifically, Resident #132 did not speak English as their primary language. The Comprehensive Care Plan did not identify that Resident #132 had a language barrier. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that a Physician reviewed each resident's total program of care, including treatments and medications. Specifically, Resident #132's Medical Orders for Life-Sustaining Treatment form documented the resident is to be intubated (when a tube is inserted through a person's mouth or nose to open an airway) and provided with long-term mechanical ventilation (to use a ventilator for breathing), including tracheostomy (an opening into the trachea from outside of the neck). Resident #132's Medical Orders for Life-Sustaining Treatment form was not reviewed since the form was first completed on 7/20/2023. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that all residents were provided with medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one of two residents reviewed for Advanced Directives. Specifically, Resident #132's Medical Orders for Life-Sustaining Treatment dated 7/20/2023 indicated the resident was to be intubated (when a tube is inserted through a person's mouth or nose to open an airway) and provided with long-term mechanical ventilation (to use a ventilator for breathing), including tracheostomy (an opening into the trachea from outside of the neck). [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification and Abbreviated Survey (NY00303374) initiated on [DATE] and completed on [DATE] the facility did not ensure that each resident receive adequate supervision and assistance to prevent accidents. This was identified for one (Resident #82) of two residents reviewed for falls. Specifically, Resident #82 required total assistance of two staff members for all areas of Activities of Daily Living (ADLs) including bed mobility as per the Comprehensive Care Plan (CCP). During morning care on [DATE] Resident #82 fell in their room, when the Temporary Nursing Assistant (TNA) #1 turned the resident on their right side away from them (TNA #1) without the assistance of another staff member. Subsequently, Resident #82 fell from their bed and sustained Bilateral Femur (upper leg) Fractures. [...]

Inspectors wroteBased on record reviews and interviews conducted during a Recertification Survey and Abbreviated Survey (NY00308707) initiated on 7/19/2023 and completed on 7/28/2023, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury are reported to the New York State Department of Health (NYSDOH) within the required timeframe. This was identified for one of four sampled residents reviewed for Accidents. Specifically, Resident #230 was first identified on 1/14/2023 with a right hip fracture and the facility did not report the injury to the NYSDOH until 1/16/2023. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 7/19/2023 and completed on 7/28/2023, the facility did not ensure that accurate preadmission screening for individuals with a mental disorder and individuals with intellectual disability was conducted. This was identified for one of 35 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, Resident # 143 had a Level I (one) PASARR screening partially completed; therefore, the necessity of a Level II screen could not be determined. The finding is: The facility's policy and procedure titled Pre-admission Screening and Resident Review (PASARR) last revised June 2021 documented to obtain a pre-admission screen for all new admissions and to review the PASARR screen for every new admission. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 7/19/2023 and completed on 7/28/2023 the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #60) of two residents reviewed for Respiratory care. Specifically, Resident #60, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a Physician's Order to administer continuous oxygen at 3 liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). The resident was observed in the dining room with an empty oxygen tank. The finding is: [...]

Inspectors wroteBased on record review, observation and interviews during the Recertification survey initiated on 7/19/2023 and completed on 7/28/2023, the facility did not ensure a resident requiring dialysis services received such services consistent with professional standards of practice. This was identified for one (Resident #83) of one resident reviewed for Dialysis. Specifically, Resident # 83 received Dialysis services twice per week at a Dialysis Center not located within the facility. There was no documented evidence that ongoing communication and collaboration with the dialysis facility regarding dialysis care and services was established for Resident #83 from 7/16/2023 to 7/24/2023. The finding is: The facility's policy and procedure titled Dialysis last revised July 2018 documented that the staff will assure the coordination of care and communication with the dialysis center. [...]